Asthma guideline update

Paediatric Nursing

The first version of the BTS/SIGN guideline for the management of asthma in children and adults was issued in 2003. This updated version incorporates evidence developed in the Intervening years. It addresses all aspects of management from diagnosis through pharmacological and non-pharmacological treatment, inhaler devices, education, organisation of services and patient education. A summary of some of the main recommendations is given here - please refer to the full guideline if you intend to review or update your practice in this area.

Diagnosis

The probability that the child has asthma increases with the presence of more than one of the following symptoms: wheeze, cough, difficulty breathing, chest tightness - particularly if these occur apart from colds or: are frequent and recurrent; worse at night and in the early morning; occur in response to, or are worse after, exercise or other triggers such as exposure to pets, cold or damp air or occur with emotions or laughter.

Other features that increase the probability of asthma are:

* history of atopic disorder in the child

* history of atopic disorder or asthma in the family

* widespread wheeze heard on auscultation

* improvement in symptoms or lung function in response to adequate therapy.

Severe and life-threatening asthma

Children with acute severe or life-threatening asthma must be transferred urgently to hospital to receive frequent doses of nebulised β^sub 2^ agonists. In acute severe asthma, the child is tachycardic and tachypnoeic; she or he cannot complete sentences in one breath or is too breathless to talk or feed. The situation is life threatening if there is hypotension, exhaustion, confusion, coma, silent chest, cyanosis or poor respiratory effort.

Non-pharmacological management

More research is needed to obtain evidence of whether the control of environmental or dietary triggers or other nonpharmacological interventions are effective. Based on the limited evidence currently available, the guideline recommendations include:

* breastfeeding should be encouraged

* parents and parents-to-be should be advised of the adverse effects of smoking

* weight reduction should be encouraged in obese patients

* reducing exposure to house dust mite may help

* immunotherapy can be considered in specific cases

* Buteyko breathing technique (focusing on control of hyperventilation) may help

* air ionisers are not recommended for the treatment of asthma.

Aim off management

Control of asthma is defined as:

* no daytime symptoms

* no night time waking due to asthma

* no need for rescue medication

* no exacerbations

* no limitations on activity, including exercise

* normal lung function (FEV^sub 1^ and/or PEF >80 per cent predicted or best),

with minimal side effects.

The step wise approach

Five steps are used in the management of asthma (the fifth is not used in children under five). Patients are moved up the steps to improve control and down to find and maintain their lowest controlling step. The steps are:

1. mild intermittent asthma

2. regular preventer therapy

3. initial add-on therapy

4. persistent poor control

5. continuous or frequent use of oral steroids.

Before initiating new drug therapy, practitioners should check compliance with existing therapy and inhaler technique and eliminate trigger factors. For most patients, exerciseinduced asthma reflects poor control and regular treatment should be reviewed.

Supporting self-management

All people with asthma should have access to primary care services delivered by doctors and nurses with appropriate training In asthma management. Inhaler devices should only be prescribed after the child/young person and family have received training in the use of the device and have demonstrated satisfactory technique. Written, personalised action plans as part of self-management education have been shown to Improve health outcomes for people with asthma. The 'Be in Control' asthma action plan from Asthma UK can be downloaded from www.asthma. org.uk/control. Initiatives that encourage regular structured review incorporating self-management education should be used to Increase ownership of personal action plans.